Texas Pandemic Influenza Regional Conference Regional Medical Director Presentation

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Texas Pandemic Influenza Regional
ConferenceRegional Medical Director Presentation
Texas Department of State Health Services
(DSHS) and Texas Division of Emergency Management
(DEM)August and September, 2009
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Presentation Goals

• Describe previous pandemics of influenza and
  their influence on planning assumptions
• Describe the initial response to novel H1N1
  influenza
• Describe Texas preparation for second wave
• Discuss coordination of efforts and what you and
  your community need to consider in preparation
  for H1N1 (next steps)

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Influenza Virus Infection
General Characteristics

• Sudden onset of symptoms
• Incubation period 1-4 days
• Infectious period 5 days, starting 1 day
  before symptoms (longer in children)
• Fever, headache, cough, sore throat, aches,
  possibly vomiting and diarrhea
• 50 of individuals with typical seasonal
  influenza have contact with the health care
  system (ranging from a doctor visit to hospital
  admission)

Several types of influenza virus are circulating.
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Pandemic

• Definition A disease outbreak occurring over a
  wide geographic area and affecting an
  exceptionally high proportion of the population
• The June 2009 declaration of a pandemic by the
  World Health Organization is an indication of the
  spread of the disease,
• not the severity.

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Recorded Influenza Pandemics
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20th Century Influenza Pandemics

• 1918 Spanish Flu
• Highest number of known flu deaths
• More than 500,000 people died in the US
• 20 to 50 million people worldwide died

• 1957-58 Asian Flu
• 70,000 deaths in the United States
• First identified in China in late February 1957
• Spread to the US by June 1957

• 1968-69 Hong Kong Flu
• 34,000 deaths in the United States
• First detected in Hong Kong in early 1968
• Spread to the US later that year

• 1976 Swine Flu
• The pandemic that did not happen

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The 1918 Influenza Pandemic U.S. Influenza and
Pneumonia Deaths by Age
1911 -1917 (Lower Line)
1918 (Upper Line)
Deaths per 100,000 population
Age Divisions
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How Health and Community Leaders Responded

• By advising
• Cough control
• Hand washing
• Avoiding crowds
• By establishing
• Alternative sites for medical care
• By issuing
• Ordinances to limit large public gatherings

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Liberty Loan ParadePhiladelphia September 28,
1918
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Community Mitigation 1918 Pandemic Flu Mortality
in Philadelphia St. Louis
Philadelphia
Death Rate/100,000 Population
St. Louis
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Novel H1N1 Virus Pandemic Influenza

• Its not a matter of If
• but a matter of When
• Now!

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Texas Confronts Novel H1N1 Virus

• April 17 - The CDC lab confirmed the first
  novel H1N1 virus result from California 
• April 23 - DSHS received laboratory
  confirmation of novel H1N1 virus in two teenagers
  from the same school in Guadalupe County
• April 24 - Confirmation of flu-like illness in
  Mexico reported
• - DSHS activated the MACC, the departments
  emergency operations center
• April 25 - Decision to close Schertz-Cibolo
  High School was made
• - A third student from the same Guadalupe
  County school was also confirmed to have novel
  H1N1 virus
• - Governor Perry made an initial request for
  antivirals through the Strategic National
  Stockpile

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Texas Confronts Novel H1N1 Virus

• April 26 - Initiated daily statewide State
  Operations Center conference calls
• - Governor Perry increased the request for
  antivirals to 850,000 courses
• - As of this date, the Government of Mexico had
  reported 18 laboratory confirmed cases of novel
  H1N1 virus
• - All 14 schools in the Schertz-Cibolo Universal
  City ISD closed
• April 29 - Confirmation of 1st death in
  Texas/United States
• May 5 - CDC announces new guidelines for
  school closure
• May / June - End of school year

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Texas Confronts Novel H1N1 Virus

• June 11 - W.H.O. declares pandemic
• June 17 - Lab confirmed case at summer camp
  in Tyler
• July 31 - Approximately 5,200 Texas cases
  confirmed to date
• August 24 - School starts

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Pandemic Influenza Planning Assumptions Prior to
April 2009
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Principal Activities H1N1 Response

• Epidemiological investigation
• Laboratory testing
• Guidance for clinicians, organizations,
  communities
• Distribution of Strategic National Stockpile
  antivirals
• Communication to the public

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Signs and Symptoms of Novel A (H1N1) Cases
Reported to DSHS April May 2009
Critical point 88 of the confirmed H1N1 cases
met Influenza Like Illness (ILI) case definition
(fever gt 100ºF and sore throat or cough)
Based on early cases when we were doing general
surveillance
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Descriptive Statistics of Novel A (H1N1) Cases
Reported to DSHS April May 2009

Based on early cases when we were doing general
surveillance
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Age Distribution for Certain H1N1 Cases Compared
to Populationas of July 27, 2009
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Regional Surveillance Summary H1N1 Influenza as
of July 29, 2009
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PerspectiveSeasonal vs. H1N1

• Each year in Texas, its estimated that influenza
  viruses have the following impact
• Between 1 and 5 million people sick
• Over 16,000 people hospitalized
• Nearly 3,000 people die each year
• To date in Texas, the novel H1N1 virus has had
  the following impact
• 5,200 sick
• 270 hospitalized
• 28 people have died
• The impact of novel H1N1 virus in the upcoming
  flu season will raise the number of people
  sickened, hospitalized, or killed
• The degree of impact is unknown

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2009 H1N1 Response After Action Report
Hot Wash Sessions
Phase 1 After Action Process
May 20-28
June 4
June 2
June 11
June 12
1
4
CDR Review
DSHS CO Hot Wash
HSR Hot Wash Austin
Hot Wash with Partners
2
5
M
J
J
Draft AAR in progress
3
A
This is a hot wash with partners and
stakeholders in Austin

• What went well
• Epidemiological investigation
• Lab testing
• Guidance for clinicians, organizations
  communities
• Antiviral distribution
• www.Texasflu.org

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2009 H1N1 Response After Action Report (contd)

• What went well
• Bi-national coordination that occurred between
  Mexico US
• Epidemics know no borders
• COOP Planning
• Still room to improve
• Call Center
• Call Center responded to 7500 calls, including
  almost 2,000 from medical
  providers
• Staffed with 8 nurses, 8 staff (minimum of 2
  bilingual)

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Novel H1N1 Virus Presented Challenges in Texas

• Big home rule state
• Sheer size of Texas is itself a challenge
• Disaster response is established as a local
  responsibility state plays crucial support role
• Laboratory capacity
• DSHS lab and Laboratory Research Network (LRN)
  handled over 30,000 samples during the spring
  response
• Lab became a diagnostic laboratory rather than
  serving as a surveillance lab

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Novel H1N1 Virus Presented Challenges in Texas
(contd)

• Novel virus Spread and Severity?
• When virus first appeared, we needed to know more
  about H1N1
• Was it more serious and did it impact the same
  populations as seasonal flu
• Complexity of local school closures public
  events
• Impact can be community-wide, impacting employers
  and essential services
• Communicating the right messages
• Finding the balance between reporting the news
  and not creating panic

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Lessons Learned in 2009

• Young adults MAY experience higher than expected
  mortality rates from a novel (new) strain of
  influenza virus
• Severity of illness MAY be lessened by prior
  exposure to a genetically related influenza virus
  
• Targeted, layered non-pharmaceutical
  interventions (NPI) MAY help mitigate the impact
  of flu on communities

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Lessons Learned in 2009 (contd)

• Timely closure of large public gatherings MAY
  help diminish the peak number of people who are
  ill with the flu in a community at any one time
• Outpatient and inpatient medical care facilities
  WILL be overwhelmed when the number of people who
  are seriously ill at any one time exceeds each
  communitys medical surge capacity.

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Preparing for Flu Season DSHS Planning Efforts
Work Groups
Stakeholder Input (e.g., PCC, SAAC, etc.)
Phase 2 Work Groups
May 20 July 3
July 3 - 31
July 24
July 31
A
B
C
Executive Review
M
Z
D
E
J
J
A

• Medical Surge
• Non-Pharmaceutical Interventions
• Epidemiology
• Lab role

• Vaccinations
• Antivirals
• Protect Health Care Workers

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In Depth Coverage to Follow

• Non-Pharmaceutical Interventions
• Epidemiology
• Laboratory
• Vaccinations
• Antiviral Medications

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Medical Surge Capacity Hospital Beds

• Texas has 550 hospitals with 80,000 beds
• We have a surge capacity of about 9,000 beds
• Texas population is 24 million
• Texas is working to develop an inventory of
  medical supplies and equipment

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Medical Surge CapacityAlternative Care Systems

• Try to care for ill people at home if possible
• Home care guidance (provided through call
  centers)
• Guidance on when to seek medical care
• Expand outpatient capacity
• Flu clinics
• ER capacity (tool kits available)
• Postpone non-essential healthcare activities if
  needed
• Identify local nursing home capacity
• Identify hospital surge capacity strategies for
  critical populations (Pediatrics, OB, Critical
  care)
• Develop alternate care sites as last option.
  Texas has approximately 22,000 alternate care
  site beds identified

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Medical Surge CapacityProtecting Healthcare
Workers

• Healthcare Workers (HCWs) MUST get seasonal H1N1
  flu vaccine (In past flu seasons, only 45 of
  health care personnel got flu vaccinations.)
• HCWs should also get the novel H1N1 virus vaccine
  when it becomes available.
• HCWs should also get a pneumococcal (pneumonia)
  vaccination as recommended.
• Educate HCWs about and encourage proper
  implementation of
• Appropriate infection control precautions
  (including staying home when sick)
• Correct use of Personal Protective Equipment
  (such as masks) and hand hygiene
• Communicating confirmed infected patients present
  in facility
• Heighten surveillance of health facility-related
  infections and report unusual cases and clusters

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Non-Pharmaceutical Interventions
Non-Pharmaceutical Interventions (NPI) include
methods to reduce spread of disease (e.g.,
community mitigation, good hygiene, staying home
when sick)
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Non-Pharmaceutical Interventions (NPI)Goals for
NPI
1. Reduce those exposed 2. Reduce burden on
hospitals 3. See fewer outbreaks
From Community Strategy for Pandemic Influenza
Mitigation (CDC, February 2007)
1
Pandemic outbreak No intervention
2
Pandemic outbreak With intervention
Daily Cases
3
Days since First Case
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Pandemic Severity Index
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CDC Recommended Community-based Strategies
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Novel H1N1 Detection and Monitoring by DSHS

• Sentinel surveillance
• Hospital surveillance
• Mortality surveillance
• H1N1 surveillance same as seasonal flu
  surveillance

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Laboratory

• The public health laboratory must be used to
  answer public health questions and not as a high
  throughput clinical laboratory
• Testing to support monitoring and investigation.
  Findings are crucial in developing and updating
  treatment guidance
• Collection submission criteria enrolled
  sentinel surveillance providers will submit
  specimens to the DSHS Infectious Disease Control
  Unit (IDCU)
• Monitor changes in virus type
• Surge capacity strategies planning and
  partnerships to address surge demands

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Novel H1N1 Vaccinations Population Priorities

• Initial Groups Targeted for Vaccinations (not in
  priority order)
• Pregnant Women
• Household contacts of babies under 6 months of
  age
• Health care and emergency medical services
  workers
• Children and young people age 6 months through 24
  years
• People between 25 and 64 years who have chronic
  medical conditions
• Total of priority targets 159 million Americans

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Antiviral Medications for Influenza

• Inhibits the growth or reproduction of the virus
• Antiviral medications are available in the normal
  marketplace
• Antiviral medications are just one piece of the
  response effort
• If given within 48 hours of exposure or before
  exposure antivirals may
• Prevent disease, but only while medication is
  taken
• No long term protection
• If given within 48 hours of symptoms antivirals
  may
• Reduce length of illness by 1-2 days
• Prevent severe complications

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Collaboration Efforts
Incident Commander with Planning and
Intelligence Chief at the DSHS MACC
Press Conference with the Governor
Epidemiologists investigated deaths, established
what data and specimens needed to be collected
established policy
Inspection of the SNS antiviral allotment
EPI team hard at work
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Meeting Texas Health ChallengesRequires
Effective Collaboration
Hospitals

• Public Health

Health Care Providers
Community-based Solutions
Elected Officials
Faith-based organizations
Volunteer Organizations
Worksites
Higher Education
Other organizations
Schools
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Public Health Messages

• Practice good hand hygiene
• Practice cough/sneeze etiquette
• Be prepared to get sick

• Stay home when you get sick
• Get your flu vaccinations (shots or sprays)
• No aspirin for kids when they are sick
• Get pneumococcal vaccine as recommended

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www.TexasFlu.org
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Next Steps

• Plan now with others in your community
• local governments, health departments, trauma
  regional advisory councils, hospitals, doctors,
  schools, businesses, etc.
• Encourage (or require if appropriate) both
  seasonal and novel H1N1 virus vaccinations
• Encourage common sense measures
• like washing hands, covering coughs and sneezes,
  staying at home when sick with flu-like symptoms,
  etc.
• Engage in continuity of operations planning at
  work, personal readiness planning at home

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Next Steps (contd)

• Plan for increased demand for healthcare services
  within your community
• Also plan for increased demand for mortuary
  services
• Dont assume help will be available from nearby
  jurisdictions, the state, or the feds
• Every community and every level of government
  will likely be impacted
• Promote readiness and self-care in your
  communities among those who are able

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Resources

• www.TexasFlu.org
• www.TexasPrepares.org
• www.TEA.state.tx.us
• www.TDA.state.tx.us
• www.flu.gov

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Thank You!